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possible the effects of shock. With this object I alwaystake care that the body and limbs of the child are wrapped’in flannel bandages, and during the operation the patientlies upon a large, flat, hot-water tin, covered over with ablanket, which fits on the operating table. If hot fomenta-tions are applied to the lower parb of the abdomen andperineum afber the operation, the child will usually passurine in the course of a few hours without any straining ordifficulty, and, beyond a slight smarting, with very little

nain, usually much less than previously to its performance.In only one of my cases has there been any rise of tem-perature, and the following morning the patients have allbeen practically convalescent. Ib is, however, advisable tokeep them in bed till the third or fourth day, when they maysit up in the ward, and at the end of a week they are usuallyquite fit to leave the hospital. In each instance theoperation was performed with Weiss’s Nos. 5 and 7 children’slithotrites, and the fragments removed with Nos. 6 or 8evacuating tubes. In Case 4, as the stone was too large tobe crushed with No. 7 lithotrite, it was first broken upwith one of Weiss’s small lithotrites for adults (aboutNo. 9 size), and the operation was completed with Nos. 5and 7 lithotrites. This case illustrates the fact that acalculus of considerable size—viz., over an inch in diameter-may be safely crushed in a young child. I believe thatin the future lithotrity will quite supersede lateral litho-tomy in children, and also that if a stone is too largeto be crushed, it will be an indication for the selectionof the supra-pubic operation.

Manchester.

A CASE OF HEMICHOREA FOLLOWED BY PARA-LYSIS (PARTIAL HEMIPLEGIA) IN A CHILD

FOUR YEARS OF AGE.

BY E. A. PIGGOTT, L.R.C.P, & S. EDIN., L.S.A.LOND.

THE following case is of interest not only as occurring inso young a child, but also as exemplifying the embolic

theory in the causation of chorea. The partial hemiplegia,I take it, as clearly indicating cerebral breach of structure,in all probability dependent upon capillary embolism. Forthe early history of the case I am indebted to the parentsof the child, at which period she was under the care ofanother practitioner. The case came under my observa-tion only a short time before the development of thehemiplegic symptoms. M. D-, aged four years, thechild of healthy parents, &u6ered more or less fromconvulsions during dentition, the commencement of whichwas delayed until she had attained the age of eighteenmonths. When she had completed her fourth year shewas attacked with influenza, which was generally epidemicat the time (March, 189U). Daring the interval of timebetween the subsidence of the convulsions synchronouswith dentition and the attack of inf1aeDzi!. the child en-

joyed perfect health. The attack of inflllenza was succeededby marked choreic movements in the left upper extremity,the facial muscles on the left side being the next affected ;the disease, assuming a decidedly progressive character,ultimately reached the left lower extremity. The mus-cular contortions were almost entirely limited to theleft side of the body, and were often present duringsleep, frequently causing the little patient to awakewith a sudden start. Locomotion was also interfered with,the left leg being drawn along the ground in walking. Anourishing dieb, consisting of milk, beef-tea, eggs, &e.,was ordered, and a mixture containing compound syrupof the hypophosphites, combined with small doses ofliquor arsenicalis, together with cod-liver oil, prescribed.Under this treatment there was a marked improvement inthe choreic symptoms ; the improvement, however, was ofbrief duration. Decided evidence of hemiplegia soon com-menced to manifest itself, paralysis of the left facialmuscles, partial ptosis, and considerable photophobia, withloss of power in the left arm to such an extent that therewas complete inability to grasp any object, the childusing the right hand to endeavour to assist the left,finally being unable to life the arm at all. The bowelswere relieved naturally until this date (Oct. 13b, 1890).On Oct. 15th I was called to see the patient, as the sym-pboms were alarming. On arrival I found the followingcondition - viz , pupils unequal, lef dilated, right con-

tracted ; the conjunctiva of the left eye totally insensitive.with diminished sensibility in right conjunctiva ; markedtrismus, the jaws being firmly closed. Tonic contractionof the extensor muscles of the left arm and forearm andboth legs, the left being the most complete. Temperaturein axilla 100° ; pulse about 120, weak ; respiration normal;child groaning slightly at intervals, and moving the head fromside to side. A small quantity of liquid nourishment wasadministered by forcibly separating the jaws. During theprogress of the disease, especially after the paralybic sym-ptoms developed, the child was constantly complaining ofpain in the head, and would cry out suddenly, frequentlyawaking from sleep with a scream—Oct. 16bh : The con-dition to-day nearly approached that of complete coma.Temperature normal ; muscular jerkings almost continu-ous in the left upper extremity, which remained rigidlyextended. The fingers were clenched, and the handdrawn back to such an extent that it almost resembled inappearance a complete dislocation at the wrist-joint, bothfeet being similarly affected, and simulating the conditionrepresented in a case of talipes equino-varus. The bowelswere obstinately confined, the urine being passed involun-tarily. From this date the patient gradually passed intoa state of profound coma, sordes forming upon the lips,with a total inability to take nourishment, death finallyreleasing the little sufferer on Oct. 23rd. A post-mortemexamination was not permissible.

.. --

The foregoing case, in a great many of its details,resembles tubercular meningitis. Both patents being youngand vigorous, there was no reason for supposing the childdirectly inherited a tuberculous diathesis ; doubtless a

tendency to brain mischief existed, owing to the convulsionsattendant upon dentition. Ib is also a question what share,if any, the attack of influedza had in the production of thefatal cerebral symptoma.

Clare, Suffolk.

ATRESIA ANI.

BY JOHN K. MURRAY, M.B. EDIN.

A WELL-DEVELOPED child three weeks old was broughbto me in September, 1891. I found a dimple marking theusual site of the anus, and the faeces passed per vaginam.On passing a probe the fistulous communication could notbe found. Under ether, administered by my friend, Dr.Batchelor of Queen’s Town, I cut down on the normal siteof the anus, dividing the tissues in the middle line to thedepth of an inch and a half. I could find no rectal cul-de-sac. The depth of the wound precluded further dissection.To get freer access I partially divided the posterior vaginalwall, and having passed a probe into the posterior fornix

vaginæ I at last succeeded in making it enter the bowel.By inserting my forefinger into the wound I found the pointof the probe just a little behind the vaginal wall. I accordinglycut down on it. This was followed by a free gush of faeces.I put a stitch in the site of the recto.vaginal septum andclosed the vaginal opening by absorbent wool. A bulbous silkcatheter was tied in the rectum. The wound was syIingeddaily. By the third day no fæces escaped per vaginam.The catheter was removed, and passed into the bowel fourtimes daily. When seen in the early part of March,1892, it was found that a well-formed anus was present,rather nearer the vagina than in the normal perineum. Nofæces have escaped since the third day per vaginam.In this case the dimple marked the arrested deepening of

the epiblastic fold which grows into and becomes continuouswith the mesenteron. The high site of the rectal cul-de-sac probably indicates a defect in the developmentof the mesenteron itself. As regards the operation, themain difficulty was in striking the cul - de - aae, whichwas not distended by fæces, free egress being afforded bythe vagina frequently during the operation. It is recom-mended by Dieffenbach and Barton 1 that, if possible, thecul de-sac should be detached from the vagina and stitchedto the skin. This may be feasible where the cul-de-sc isblind or where it comes low down, but where the cul-de-sac terminates at its communication high up in the fornixvaginae such a proceeding is difficult, even hazardous. Theresult in this case shows the tendency of nature to revertto normal channels when such are re-established. The line of

1 Medical Recorder, vol. vii., p. 357.

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force was in the direction of the wound when defecationtook place, consequently the healing of the trench-shapedwound formed a natural prolongation of the rectum endingat the skin.Whittlesea, Cape Colony.

DIFFUSE HÆMATOMA OF THE BACK; DEATH.BY G. OSCAR JACOBSEN, M.R.C.S., L.R.C.P. LOND.

I WAS called on March 18th to see T. E-.-, who, I wasinformed, had on the previous night hurt his back in a fall.On arriving I found that the patient, a man aged fifty-eight,seemed to be in considerable pain, and on examination ofthe back discovered a large swelling, which correspondedroughly in site and size to the right scapula. The tumour

appeared to be fluid, as there were distinct evidences offluctuation. There was no discolouration of the skin.From the history I took it to be a hæmatoma, and prt.-scribed a lead lotion, rest, and sedatives. I was unable toobtain ice. The patient, I was told, had got up from thesofa, and was crossing the room, and during the momentaryabsence of his wife was seized with an attack of giddiness,and had fallen with all his weight with the right side of hisback against the sharp jamb of the door-post. I had beenattending him for kidney disease, and what I took to beMeniere’s disease, the patient complaining of constantattacks of vertigo associated with one-sided deafness. Thenext day, the 19th, the man seemed no worse, but theswelling had increased. The third day he seemed in a gocddeal more pain, and the swelling now extended upwardsunder the muscles of the right side of the neck nearly ashigh as the mastoid process, downwards to the small of theback, and had, moreover, now become very much discoloured.The next night I was sent for again, and found the patientin a very bad way, delirious, with running pulse and greatdyspnœa—in fact, moribund, and he died the next morning,the 23rd, at 5 A.M., a little over five days from the time ofthe accident. A necropsy was ordered by the coroner, whichI made about thirty hours after death. On inspection therewas found to be considerable swelling on the right side fromthe mastoid process to the lumbar region. This was dis-tinctly fluctuating, and there was very great discolourationof the skin. not due to post-mortem changes. On openingthe chest the first thing noticed was infiltration of all thepectoral muscles of the right side with blood. On dissectingthem carefully back this was found to become more andmore intense, and after reaching a point just behind themid-axillary line there was found underneath the latissimusdorsi a huge cavity which contained over three pints ofsemi-fluid and coagulated blood. The intercostal muscleswere sodden with blood, and at one point seemed breakingdown into the pleural cavity. The right pleural cavitycontained a fair quantity of blood-stained fluid, and towardsthe base some very recent lymph, which also was found onthe surface of the base of the lung. The lungs appearedhealthy, and the other organs appeared fairly healthy, withthe exception of the liver, which was somewhat enlarged.and the kidneys, which were granular, with diminishedcortex, and the capsule very adherent. There was atheromaof the aorta and thickening of the aortic valves.This case I think interesting and worthy of record, owing

to the comparatively slight injury-namely, the fall againstthe door-post-the large amount of blood effused, and theconsiderable length of time elapsing before death. Theextent of the hæmorrhage I attributed to the brittle stateof the arteries consequent upon the patient’s kidney disease.Ashwell, near Baldock.

FOOT-AND-MOUTH DISEASE IN KENT.-The foot-and-mouth disease in the Sittingbourne district is, it isstated, increasing, and threatens to become epidemic. Thethird outbreak in the course of a few days was reported onthe 16th inst., when it was discovered that the malady hadmade its appearance among a flock of about 150 sheep onOakwood Farm, near Sittingbourne, belonging to Mr. G. H.Dean. This latest outbreak has had the effect of extendingthe boundary of the infected district. This was apparenton Good Friday, when a large number of pedestrians whoattempted to pass through Gore Court Park found several ofthe footpaths closed to the public and guarded by police.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mer-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb.,lib. iv. Proœmium.

WESTMINSTER HOSPITAL.ENTERIC FEVER ; RIGHT HEMIPLEGIA WITH APHASIA;

RELAPSE ; DEATH.(Under the care of Dr. DONKIN.)

THIS case is placed on record on account of the excep.tional occurrence of hemiplegia in connexion with entericfever. In connexion with this case Dr. Donkin observedthat some few cases have been reported, but mostly withoutnecropsies. Two cases in children with recovery were

recorded by Dr. Gee and Dr. Cayley respectively in theMedical Times and Gazette for 1878, vol. i. The blockingof the cerebral arteries is usually put down, according toinference from probability, to an embolic cauee, and whereno cardiac abnormality is demonstrated or indicated theembolism is supposed to arise from a broken-up thrombusin the left heart. In this case there was nothing noteworthyin the heart’s structure or contents. We have probably tochoose between thrombosis in situ or some temporaryclotting in the heart’s cavities leading to embolism forexplanation of the arterial blocking which was discoveredboth in the brain and the lung. It seems much more,

probable that both the clots found were produced in situ,and that their cause was the same-viz., depression of the.circulatory force from the long and severe pyrexia, whichwas evidenced by continuous dicrotism of the pulse andgreat weakening or silence of the first sound of the heart.Direct impairment of the nutrition of the arteries was apart of the profound effect of continued and especially ofenteric fever on the tissues generally, and morbid changesin the blood were probably important co-factors with theweakened heart in producing the result. It must be remem-bered that the patient had an extensive bronchitis withmuch dyspnoea, causing excessive stress on a heart alreadyoverworked and probably dilated in the course of the fever.In this context Dr. Donkin called attention to a caserecorded by Dr. J. Abercrombie where sudden left hemi-plegia occurred in a boy of six years old with diphtheria,the necropsy showing thrombosis of the right middlecerebral artery without valvular heart disease or evidenceof embolism. The account of the case is abstracted fromnotes furnished by Mr. Gossage, house physician.The subject of this record, aged thirty, had been nursing

two cases of enteric fever in a house where the drains werebelieved to be very defective. One of these cases died aftera severe course of the fever with profuse fetid diarrhoea.The nurse began to feel ill while at her duties a fortnightbefore admission to hospital on Dec. 2nd. On Nov. 28thshe had severe headache, and on the following two dayssuffered from pains all over, and shivered repeatedly. OnDec. 2nd there were slight cough, slight diarrhœa, and somevomiting. She was the subject of chronically enlargedglands in the neck, which had been getting larger duringthe three weeks before admission; had bad "strumousconjunctivitis" two years before; and attacks of influenza.in January, 1890, and May, 1891, the last being severe. Onadmission, the temperature was 104° F., and there wassome distension, with great pain and tenderness of theabdomen. From this date to the 15th the temperatureranged between 1048° and 102°, being usually over 103°,and there was much abdominal pain, occasional vomiting,and abundant eruption. After five days’ constipation, a.simple enema was given on the 8bh, and subsequently therewere from one to three semi-solid or solid motions on mostdays till the 15th, when fairly marked morning remissionsof temperature set in. On the 15th bronchitic signs wereheard all over the chest. The bronchitis became severe,with considerable dyspnoea, for several days, and the tem-

perature ranged generally between 101’5° and 103°, occa.